Posted by AskNurseLinda on Nov 5, 2018 8:38 am

ce2268e823041831acb56ac59a71a2ae-huge-isAh, a breath of fresh air. Feels great. But a good, deep breath can be difficult for many to obtain. Breathing is a complicated system. The body works hard to bring air in and expel it when used. It is vital for life. Keeping your breathing healthy is a work in process.

Breathing occurs as a result of the functioning of the respiratory system. The lungs are like bellows. They take the air available in the world and actually pull it into the body. Deep within the lungs, there are little sacs that allow oxygen molecules to cross the boundary of the body and be absorbed. The air must be able to travel into these little sacs called alveoli. Once there, oxygen is extracted, and carbon dioxide expelled.

How the air gets in to the lungs is complicated because it is inhaled or sucked into the body. To get air in, the diaphragm pulls down which makes the lungs elongate within the body. While this is happening, the small but powerful muscles between the lungs, called the intercostals, cause the lungs to expand all the way around. The intercostals, are pulling the lungs out while the diaphragm pulls the lungs down, really making them larger in size in all directions. The third part of breathing are the abdominal muscles which when activated lead to a negative pressure in the lungs. Because of the newly created vacuum in the lungs, air is drawn in.

When air is expelled the three parts of breathing, the diaphragm, intercostals and abdominal muscles relax. When the ‘big three’ are opening the lungs, they are activated. Interestingly, when air is expelled out of the lungs, the ‘big three’ are relaxed. They are not working to push air out but rather air is released when the activation is stopped. This allows the lungs to return to their non-expanded shape and size. This is sort of interesting because the body works to bring in air but when relaxed air is expelled.

When air is brought into the lungs, oxygen is extracted from the air, moves through the boundary of the body through the alveoli but as oxygen moves in, carbon dioxide travels out. Carbon dioxide is waste that that is being removed from the entire body through the circulatory system via blood.

What makes the diaphragm, intercostals and abdominals activate is controlled by the autonomic nervous system. It happens automatically. You cannot stop yourself from breathing. You can temporarily hold your breath but if you hold it for too long, you pass out and, if you do not have neurologic issues, your body will automatically start breathing again. You don’t have to think about breathing, it just happens.

The location of neurologic injury can affect your breathing. If you have an injury in the part of the brain called the brainstem, breathing can be disrupted. If there is an injury to the C4 or Cervical section, vertebrae 4 of your spinal cord or above, the phrenic nerve will not receive the message from the brain to make the diaphragm work. This is a major blow to the functioning of the respiratory system as it is the main activation of breathing. An injury anywhere in the thoracic area or part of the spine that has ribs connected to the vertebrae, will disrupt messages from getting to the intercostal muscles below the level of injury. Any lower level injury will affect the function of the abdominal muscles. You might not think that a low-level injury will affect breathing but indeed the abdominal muscles are needed for fully functioning lungs.

You can utilize assistance to help you breathe if required. Mechanical ventilation is typically necessary for spinal card injury above C4. There are some cases where individuals with injury at this level or above can breathe effectively without use of the ventilator probably not all of the time, but for short periods during the day. Mechanical ventilation will most likely be used at night to let the body rest from the work of breathing.

Relying on mechanical ventilation is a challenge. Interestingly, even though individuals have their oxygenation needs met by mechanical ventilation, the brain still perceives that the person is not breathing. Adapting to mechanical ventilation can produce anxiety. Individuals with tracheotomies will tell you they can be quite uncomfortable. Talking with use of a mechanical ventilator can be accomplished through the use of Passy-Muir valves or computer assisted speaking.

Specialty programs have been developed to increase respiratory muscle ability and function. Not everyone will be able to accomplish breathing off the ventilator, but more therapies and interventions are helping people reduce dependency. Research is rapidly developing in this area.

Some therapies teach patients to breathe differently so they are responding not to the need for intake of oxygen but to push out carbon dioxide. Other interventions include implanting of diaphragmatic pacemakers which supply internal electrical stimulation of the diaphragm. The advent of minimally invasive surgery and the improvement in technology of the implanted device has made this intervention a possibility for individuals with high level spinal cord injury.

Issues that affect breathing with or without mechanical ventilation, include keeping the airway clear, all the way through to the alveoli. With spinal cord injury, even without mechanical ventilation, getting that deep breath can be a challenge since it takes all the effort of the three mechanics of breathing, activation of the diaphragm, intercostals and abdominal muscles.

Therapeutic exercises can assist in improving breathing. Sitting in proper alignment will also keep your body in the best position to open the airway and avoid choking.  Turning, moving your body with in your chair by repositioning in the day and turning at night will move any collection of fluid that might consolidate in your lungs.

If ventilatory dependent, using the sign button will help expand your lungs. Otherwise, if able, taking in three deep breaths and coughing will also help move secretions. If necessary, suctioning can be used to clear larger amounts of secretions. Suctioning is uncomfortable for some individuals. An insufflator/exsufflator might be an alternative as it is softer on tissues but rather difficult to master. Secretions not only serve as a breading ground for bacteria but also cover those alveoli, keeping them from exchanging the oxygen and carbon dioxide molecules.

There are some devices that can also improve your breathing. Lung exercisers, especially incentive spirometry can help increase your muscle strength and lung capacity. You were probably provided with an incentive spirometer in the hospital but often it is not even opened.

Healthcare providers tend to overlook this device. It is a hand-held clear plastic, low tech piece of equipment that has three chambers with a plastic ball in each. The idea is to inhale and exhale to make the balls rise in the chambers. At first, you might only raise one ball part way, but improvement occurs with more practice. This opens the airway to the alveoli.

If you have mechanical ventilation or not, keeping your mouth exceptionally clean will help your airway and avoid infection. Extensive research of oral hygiene has demonstrated that if you choke on clean saliva you have less chance of infection. Decaying food, even tiny particles, already contain bacteria which leads to infection in the lungs.

As the seasons change, the weather turning from warm to cold in the fall is a perfect time for bacteria to collect in your lungs. The body becomes chilled so maintaining body temperature is important. Bacteria and viruses thrive in the fall weather and in dryness of heated buildings. Protection from the flu can be had by careful handwashing and getting your flu shot if you are eligible for receiving it. Typically, you will want to have your flu shot by October, but it is not too late now that it is November.

A good protection from pneumonia is the pneumonia vaccine. You might still get pneumonia, but it will be less severe than without the inoculation. No one enjoys an injection, but the flu and pneumonia protection afforded by these vaccinations are worth the discomfort.

Another protection for your lungs is to avoid inhaling anything into them such as cigarettes either smoking yourself or being around people who smoke, vape, use e-cigs, or other noxious chemicals such as new paint, street drugs, etc. If it stinks, you don’t want to breathe it. Don’t delude yourself that there is a safe inhalant. There is no safe inhalant.

Another issue that can occur is a blood clot in your lungs. This is called a pulmonary embolism (PE). Symptoms include shortness of breath or not being able to inhale your usual breathing amount. PE is a medical emergency. Call 911 for immediate assistance.

Keeping your respiratory system healthy takes work for all of us. We don’t really think much about breathing until it becomes a challenge. But it is critical for life for everyone. You can lead by example by demonstrating great respiratory care.

Nurse LindaI'm online in this community every Wednesday from 8-9 PM ET to answer your SCI and paralysis related questions.

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